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Basic Basic Intravenous Intravenous

TherapyTherapy90-95% of patients in the 90-95% of patients in the

hospital receive some type hospital receive some type of intravenous therapy. of intravenous therapy.

This presentation will enhance This presentation will enhance your knowledge of how to care your knowledge of how to care

for them.for them.

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Veins are unlike arteries in Veins are unlike arteries in that they are 1)superficial, 2) that they are 1)superficial, 2) display dark red blood at skin display dark red blood at skin surface and 3) have no surface and 3) have no pulsation pulsation

Vein AnatomyVein Anatomy - - Tunica AdventitiaTunica Adventitia - Tunica Media- Tunica Media - Tunica Intima- Tunica Intima - Valves- Valves

Vein Anatomy and Vein Anatomy and PhysiologyPhysiology

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Tunica AdventitiaTunica Adventitiathe outer layer of the vesselthe outer layer of the vessel

Connective Connective tissuetissue

Contains the Contains the arteries and arteries and veins supplying veins supplying blood to vessel blood to vessel wallwall

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Tunica MediaTunica Mediathe middle layer of the vesselthe middle layer of the vessel

Contains nerve Contains nerve endings and endings and muscle fibersmuscle fibers

The The vasoconstrictive vasoconstrictive response occurs at response occurs at this layerthis layer

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Tunica IntimaTunica Intimathe inner layer of the vesselthe inner layer of the vessel

One layer of endothelialsOne layer of endothelials

No nerve endingsNo nerve endings

Surface for platelet Surface for platelet aggregation aggregation w/trauma and recognition of w/trauma and recognition of foreign object at this levelforeign object at this level

PHLEBITIS begins herePHLEBITIS begins here

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ValvesValvespresent in MOST veinspresent in MOST veins

Prevent backflow and Prevent backflow and pooling pooling

More in lower More in lower extremities and longer extremities and longer vesselsvessels

Vein dilates at valve Vein dilates at valve attachmentattachment

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Veins of the Upper Veins of the Upper ExtremitiesExtremities

Digital VesselsDigital Vessels -Along lateral aspects fingers, infiltrate easily, painful, difficult to immobilize and should be your LAST RESORTMetacarpal VesselsMetacarpal Vessels -Located between joints and metacarpal bones (act as natural splint) -Formed by union of digital veins -Geriatric patients often lack enough connective / adipose tissue and skin turgor to use this area successfully

Digital

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Veins of the Upper ExtremitiesVeins of the Upper Extremities

Cephalic (Intern’s Vein)Cephalic (Intern’s Vein) -Starts at radial aspect of wrist -Access anywhere along entire

length (BEWARE of radial artery/nerve)

Medial Cephalic (“On ramp” Medial Cephalic (“On ramp” to Cephalic Vein)to Cephalic Vein)

-Joins the Cephalic below the elbow bend

-Accepts larger gauge catheters, but may be a difficult angle to hit and maintain

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Veins of the Upper ExtremitiesVeins of the Upper Extremities BasilicBasilic - Originates from the ulner side

of the metacarpal veins and runs along the medial aspect of the arm. It is often overlooked becauses of its location on the “back” of the arm, but flexing the elbow/bending the arm brings this vein into view

Medial BasilicMedial Basilic - Empties into the Basilic vein

running parallel to tendons, so it is not always well defined. Accepts larger gauge catheters.

- BEWARE of Brachial Artery/Nerve

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Purposes of IV TherapyPurposes of IV Therapy To provide parenteral nutrition To provide avenue for dialysis/apheresis To transfuse blood products To provide avenue for hemodynamic monitoring To provide avenue for diagnostic testing To administer fluids and medications with the ability to

rapidly/accurately change blood concentration levels by either continuous, intermittent or IV push method.

Types of Peripheral Venous Access DevicesTypes of Peripheral Venous Access Devices•Butterfly (winged) or Scalp vein needles (SVN) – not recommended for non compliant patient as it can easily penetrate the vein wall causing extravasation. We use these frequently for phlebotomy•Safety Over the needle catheters (ONC)

- PROTECTIV ® -ACUVANCE ®

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Starting a Peripheral IVStarting a Peripheral IV Finding a vein can be challengingFinding a vein can be challenging

- Go by “feel”, not by sight. Good veins are bouncy to the touch, but are not always visible.

- Use warm compresses and allow the arm to hang dependently to fill veins.

- A BP cuff inflated to 10mmHg below the known systolic pressure creates the perfect tourniquet. Arterial flow continues with maximum venous constriction.

- If the patient is NOT allergic to latex, using a latex tourniquet may provide better venous congestion

- Avoid areas of joint flexion- Start distally and use the shortest length/smallest gauge access

device that will properly administer the prescribed therapy

(BE AWARE: Blood flow in the lower forearm and hand is 95ml/min)

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IV Start Pain ManagementIV Start Pain ManagementOne of the most frequent contributors to patient One of the most frequent contributors to patient dissatisfaction is painful phlebotomy and IV startsdissatisfaction is painful phlebotomy and IV starts

• Use 25-27g insulin syringe to create a wheal similar to a TB skin test on top of or just to side of vein with 0.1 -0.2 ml normal saline or 1% xylocaine without epinephrine

• Topical anesthesia cream (ie EMLA) may be applied to children>37 weeks gestation 1 hr. prior to stick. It might be a good idea to anesthetize a couple of sites

• Have the patient close their fist (NO PUMPING) prior to stick

• Make sure the skin surface cleansing agent (alcohol/chlorhexidine) is dry prior to stick. Drawing this into the vein may stimulate the vasoconstrictive action of the tunica media layer

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Flushing Peripheral IV’sFlushing Peripheral IV’sUse prefilled saline and heparin flush syringes located in PYXISHeparin flush concentrations available:-100u/ml (5ml in a 10ml syringe)-10u/ml (2ml in a 3ml syringe)

Flushing intervals and amounts - Peds: q 6hrs. <22ga 1ml 0.9%NS followed by 1ml heparinized (10units/ml) saline

- Adults: q 8hrs w/1ml. 0.9%NS [3ml heparinized saline for OB]

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Dressing/Bag ChangesDressing/Bag Changes

TSM q 7 d

Changing dressings1 2 3 4 5 6 7Gauze q

2 d

Changing Sites1 2 3normally every 3d

4 5 6 7Every 7 d c MD order

Changing bags and tubing1 2 3normally every 3d

24 hrs

If respiked or meds added outside pharmacy

Physician orders are required if a peripheral catheter is left in the same site for more than 3 days.

It is best to have the pharmacy add medications to the infusion bags under laminare flow to reduce contamination

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Central Venous CathetersCentral Venous CathetersPercutaneousPercutaneous TunneledTunneled PICC’sPICC’s Implanted PortsImplanted Ports DialysisDialysis

InsertionInsertion MD @ bedside w/x-ray

confirmation

MD in OR under fluoroscopy

MD/trained RN @bedside w/x-ray

confirmation

MD in OR under fluoroscopy MD in OR under fluoroscopy

LocationLocation Visible externally.

Enters subclavian, ext.

juglar,or int. juglar vein near clavicular area

Visible ext. usually midway bet. clavicle and

nipple. Tunneled under skin &

threaded through subclavian or IJ

Visible externally around antecubital fossa, upper arm or

neck

Completely internal. Titanium or plastc port is implanted in a

surgically created pocket and catheter is threaded into

subclavian or int. juglar vein. Access is through skin into self sealing port using special non

coring needle

Visible externally. Arm

or leg placement

Material/Material/CostCost

Polyurethane$200-$400

Silicone$3500-$5000

Silicone / polyurethane$350-$500

Silicone catheter. Port is titanium or plastic w/self sealing diaphragm

$3500-$5000

Various materials

LumenLumen 2-3 2-3 1-2 1-2 2-3SuturedSutured Yes/entire life Yes, until internal

Dacron cuff healed

No Yes Yes

DurationDuration Short term 4-10 days

Long term Long term Long term Mid term

FlushesFlushes 5-10ml NaCl after use and

daily

5-10ml NaCl after use and daily

5-10ml NaCl after use and daily

10ml NaCl followed by 4.5ml heparinized saline (adults-

100units/ml; peds-10units/ml) after ea. use or monthly if not accessed

Done ONLY by IV team or dialysis

nurses

Brands/Brands/NamesNames

Arrow Howe, Triple Lumen, Subclavian, IJ

Hickman, Broviac PICC, PIC, EDPC, Arrow Howe, Gesco, PASV

Bard, Accces Port-A-Cath Bard, Tesio, Vescath, Quinton

DiscontinueDiscontinue MD or speically trained RN @

bedside

MD in OR Specially trained RN @ bedside

MD in OR MD in OR

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Central Venous Catheter Central Venous Catheter SitesSites

PICC (Peripherally inserted Central Catheter)

Percutaneous(Subclavian)

Percutaneous (IJ-Int. Jugular)Tunnelled (Hickman)

Implanted Port (single or double

lumen)

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CVC Care/MaintenanceCVC Care/Maintenance

Flush after each access or daily for catheters>21ga, q 6 hrs <21 ga-adults: 10ml saline- peds/neonates: 5ml saline (preservative free for infants <1yr)

Transparent dressing change q 7 days & prn

Percutaneous Tunneled

PICC

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CVC Care/MaintenanceCVC Care/Maintenance

Implanted Port

Flush after each use and weekly while accessed; monthly when not acessed

- 10ml saline (preservative free for pts. <1yr)

- followed by 4.5ml-5ml heparinized saline 100units/ml for adults

10units/ml for peds

Transparent dressing/ access needle change q 7days

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Site CareSite CareMonitor and document

site condition:

• Hourly for peds•Q 2 hr for adult * Indicates complication:

•Infiltration•Phlebitis•Thrombosis •Cellulitis•Septicemia

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Infiltration/ExtravasationInfiltration/ExtravasationThe most common cause is damage to the wall during insertion or angle of placement.

STOP INFUSION and treat as indicated by Pharmacy, Medication package insert or drug reference book.

Notify MD and document

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Phlebitis/ThrombophlebitisPhlebitis/Thrombophlebitis

Chemical- Infusate chemically

erodes internal layers. Warm compresses may help while the infusate is stopped/changed. Anti-inflammatory and analgesic medications are often used no matter what the cause Mechanical

- Caused by irritation to internal lumen of vein during insertion of vascular access device and usually appears shortly after insertion. The device may need to be removed and warm compresses applied

Bacterial- Caused by introduction

of bacteria into the vein. Remove the device immediately and treat w/antibiotics. The arm will be painful, red and warm; edema may accompany

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CellulitisCellulitis

Inflammation of loose connective tissue around insertion site.

- Caused by poor insertion technique

- Red swollen area spreads from insertion site outwardly in a diffuse circular pattern

- Treated w/antibiotics

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Septicemia/Pulmonary Edema/Septicemia/Pulmonary Edema/EmbolismEmbolism

Septicemia- Severe infection that occurs to a system or entire body- Most often caused by poor insertion technique or poor site

care- Discontinue device immediately, culture and treat

appropriately Pulmonary edema- caused by rapid infusion Pulmonary embolism - Caused by any free floating substances that require thrombolytic therapy for several months. Increased risk w/lower ext. Air embolism- caused by air injected into IV system. Keep insertion site below level of heart

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Vascular access device will not flush/can’t draw blood- Evaluate for kink in tubing or catheter tip against vein wall.

Vascular access device (VAD) leaking when flushed - Verify that hub access cap is connected correctly

Patient complains of pain while VAD being flushed- Assess for infiltration

VAD broken- PICC’s may be repaired. All other devices must be replaced

Call IV therapy team member for any concerns or questions.

TroubleshootingTroubleshooting

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Policy notesPolicy notesKVO rate:

Adults - 10 ml/hrPediatrics - 2-3 ml/hrNeonates - 0.5-1 ml/hr

Only until rate order received

Verification required for:•Insulin•Heparin

•Potassium•Digoxin

•Chemotherapy

LPN’s cannot push IV medications

RN’s and LPN’s can start peripheral IV’s after initial training and observation by preceptor

LPN’s CANNOT infuse blood products or high risk IV medications.

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IV Medication AdministrationIV Medication Administration Many medications require patient monitoring that cannot be done on units where the nurse/patient ratios are greater than 1:2

A patient can be moved to a unit where the ratio is appropriate for invasive/frequent monitoring or another nurse can be brought to care for the patient during the med administration

All Medications Cannot Be Administered on All Units

General Care Units:Can give meds requiring only basic physical assessment data Stepdown Units:Can give meds that require more invasive or frequent monitoring than is available on general care unitsIntensive Care Units: Can give meds that require more invasive or frequent monitoring than is available on the Stepdown units.

VANDERBILT URL LINK FOR IV MEDICATIONS:

www.mc.vanderbilt.edu/pharmacy/ivroom/IVMedAdm061003.pdf

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IV Medication IV Medication AdministrationAdministration

Sample page from the Pharmacy med administration web site

See “APPROVED FOR” section. You will find if the medication can be administered on your unit.

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Infusion Nurses Society (INS)Infusion Nurses Society (INS)

Professional Organization that sets the standards of Professional Organization that sets the standards of care for clinicians practicing in the field of infusion care for clinicians practicing in the field of infusion therapy.therapy.

Standards set by INS are reflected in our policies and Standards set by INS are reflected in our policies and procedures related to infusion therapy for health care procedures related to infusion therapy for health care providers.providers.

In a court of law, the standards set by the INS are In a court of law, the standards set by the INS are used to assess the infusion clinician’s performance. used to assess the infusion clinician’s performance.

www.ins1.org